Why Doctors Hate EHR Software

Have meaningful use incentives merely propelled sales for a lot of lousy software?

9 Mobile EHRs Fight For Doctors' Attention

(click image for larger view and for slideshow)

Maybe this will be a "no duh" observation for those who work in healthcare or health IT, but a lot of doctors really hate the electronic health records (EHR) software they're compelled to use.

As an InformationWeek staffer recently assigned to this beat after only occasionally covering health IT in the past, I was surprised how unanimously and passionately dissatisfied most doctors are with the usability of this software, which they see as draining rather than enhancing their productivity. I'm sure there are exceptions where doctors are more enthusiastic about technology, the software they are using is higher quality, or a little of both. But if you open the door to a conversation about how horrible medical records software is, you'll get an earful.

Here's what I'm basing this on. Having spent the past few months writing about massive open online courses (MOOCs) for the education beat, I was happy to discover a Coursera course on Health Informatics in the Cloud starting at just about the time that I needed to come up to speed on my new beat. I'm happy to say the instructor, Georgia Tech's Mark L. Braunstein, MD, will be contributing to InformationWeek as a columnist, so watch for that. Braunstein has spent most of his career in healthcare IT, so I think it's fair to say he's a true believer in the potential and the necessity of digitizing medical information. However, when I turned to the course discussion forums I found a message thread titled "Health IT Doesn't Fix Problems -- Good Health IT Does."

One of my classmates was a pediatrician named Dave Denton, and the point of his discussion was that he hadn't seen a heck of a lot of good health IT.

"I use several EHRs in my clinic and hospital," wrote Denton, who practices in Portneuf, Idaho. "None of them allow transmission of data between systems. They all are encumbered by poor graphic user interfaces that make it hard to see patient data in a way that makes sense and helps patient care. It is actually much harder to take care of sick patients in the ICU with our new hospital system. They also tend to hide the pertinent by scattering it through the program and displaying all types of ancillary data, time stamps, and formatted notes that are inserted to ensure appropriate coding, but get in the way of seeing what is important. I have made several errors by failing to find the correct information in the chart because it was buried in the note. Finding what is important has become a treasure hunt."

In a follow-up post on dysfunctional workflow imposed by the software, he added, "I am not one of the physicians striving to resist change and implementation of EHR. There are so many valuable things this technology can bring to medicine. I am the chairman of our information systems committee in our hospital striving to make things work, but frustrated by the poor quality of products that have been forced into the marked by unrealistic timelines."

In his posts and in an interview where he elaborated on the same themes, he made it clear that he sees the potential for health IT even though he has so far been disappointed by the reality. At about the same time that I was tuning into Denton's rants in the classroom forum, a similar very active, overwhelmingly negative conversation popped up on the LinkedIn HIMSS group, under the title "Can we turn EHR dissatisfaction around?" (Hat tip to Jennifer Bresnick, an editor at Xtelligent Media, for getting the conversation started.)

The bottom-line answer from most (but not all) of the doctors and healthcare workers chiming in on that discussion was, essentially, no, not going to happen as long as there is such a mismatch between how the software in healthcare works and how the people in healthcare work. Clearly, the government agencies promoting the technology are in thrall to the software vendors, or why would they be pushing this so hard?

Typical lament: "How did IT get more powerful than the people who actually care for patients? The answer is that IT charges by the hour, while Docs can be made to do more work for less money, that is, add 2 hours work to every day without additional compensation. If we asked IT to do the hard work, we'd have to pay them." I don't want to quote by name without permission, but another commenter identified as a medical director for a healthcare group pointed out that any drug or medical device would have to be proven in FDA testing before being adopted into a hospital, while EHR software "impacts quality of care, and expecting to improve it 'on the job' causes delays in care, complications and death. Piece of advice, if anyone of you or your family has to go to a hospital make sure someone stays with the patient because the nurses will be on the computer."

Offline, I'd been hearing something similar from a friend in my Toastmasters group who is an emergency room physician. Practicing for a speech to a professional organization he is active in, he put almost as much emphasis on the productivity drain from electronic recordkeeping (and the coming horrors of ICD-10 expanding the number of codes to remember) as he did on the reimbursement squeeze aspects of Obamacare.

In both of the online conversations I referenced, there were technologists defending the good intentions of IT. They proposed solutions like better object-oriented software to separate generalized features from the requirements of a specific institution, or better use of either voice recognition or human-powered transcription to get the doctors away from doing so much data entry. But even those arguing that good EHR software is possible tended to acknowledge that a lot of EHR software is crummy. I hear the same thing from EHR vendors when they're talking about other people's products.

Dear all I totally agree whatever you guys described about EHR software usage but as a Doctor and I have my own clinic I must share my thoughts with you.

I was not using EHR software in begging but as I feel me and my staff were investing our time on reports, prescriptions, patient details and blah blah .... One day one of my best friend Dr. Gupta suggested me to buy an EHR / EMR software, I start my searching on internet and I found an EHR system provider NORTEC SOFTWARE INC www.nortecehr.com, I contacted with them and I purchased a complete Electronic health record suit for my clinic.

Since that day I analyzed few things positive like .. I don't need to use my maximum staff, All records now on my finger tips, My patients are also happy with our services, Very user-friendly and most importantly I am saving a big part of my earning means better ROI.

At the end I must say there are a lot of advantages in EHR software utilizations.

From what I see, many issues come from the lack of communication between EMR vendors, labs, and medical devices. It'd be great if all the information was stored in the EMR but many times it's not and so patients information requires multiple clicks and signons to find out what is needed and requires manual input. It doesn't help that EMR vendors can charge an obscene amount to create connections to their solution to send/receive information to/from outside sources.

Mirth Connect seems to help save costs in many of these areas (I am a sales person for Mirth but Mirth Connect is available as a free open source solution).

I recently saw a chart on HealthIT.gov that demonstrated the more in-depth a clinic or hospital delves into an EHR system, the more satisfaction seems to go up. I wonder if maybe the high dissatisfaction that's being reported in blogs all over the internet are caused by lack of training or lack of full implementation?

The root cause of this problem is the business model of healthcare, and its protection from competition on cost and quality (unlike other industries). Until this is fixed, EHRs will be viewed as a cost center, and not as a strategic weapon to improve cost and quality.

For example, even in settings where EHRs work well and have high usability, doctors still click through Rx interaction warnings and ignore them because they take too much time to deal with. Why would they do this? Because they are not paid for quality of outcome, nor are they incentivized to minimize the net present value of the 'cost stream' of a given patient to the system.

So until these underlying incentives are changed at a systemic level, the never ending tug-of-war will continue between docs and IT in a largely zero-sum game. No other industry with real competition on cost and quality would take 20 years and find that only 5% of it's employees consistently use software (productively) at the point-of-service.

Tough to disagree with the participant comments. HealthCare IT serves two masters with widely differing agendas - administrators and caregivers. The administrative burden is to provide summary reports and billing coding for insurance and mandated government reporting. Caregivers need easy data input and timely and relevant synopsis and correlation of critical information based on inputs from various sources - for example, conflicting prescriptions from specialists treating the same patient but who are not familiar with what other regimens the patient may be under from other Doctors and caregivers. The point of the EHR was to have a single source of truth provide a global view of what is happening to a patient. Instead we have multiple systems that cannot communicate with one another - creating silos of information. This is what I am hoping the Affordable Health Care act addresses - but it will take time. WIth the Political element trying to destroy better healthcare for Americans it will take even more time. Currently we have "Health Care Systems" built from older IT building blocks and re-purposed for health. They then had to expand to include the regulatory environment, billing environment and somehow lost the plan to build an "ideal" practice UI for doctors and nurses. We need to get back to that and then use IT in the background to mate the caregiver interface with the backend billing and abstract the administrative overhead out of the way of the practice pieces. Ultimately a cloud based system based on universal rules and best practices is where we need to head. Don't see the need personally for coding methodologies and caregiver training to track my flu-shot to differ between Oregon and Alabama.

Meaningful engagement by physicians is indeed a huge problem. I work in an institution on an EHR implementation and mainenance team which consistently sees many MDs refusing to attend training and making ridiculous demands on how our small team should teach their larger collective team while continuing to fix "problems in the system" for them which often amount to not knowing how to use the system because they have refused to get training! And why is it there are so many "research" papers on physician opinions and a complete paucity of opinion by any other health-care provider? The same issue has reared its head numerous times in the past several decades with physician groups such as the AMA writing scope of practice papers on what other health-care providers can and can't do while their group consistently pushes the very work they are complaining is being stolen by other professions in a manner which is "outside their scope of practice" on those said other providers by pysicians because they don't want to do the work. (I am also a practicing Pharmacist.)Double-speak among MDs is common. Many meetings we have contain both the satements "the system didn't tell me I should..." or "the system didn't warn me about..." along with "I'm alert fatigued". You can't have it both ways! It is also not uncommon to have a discussion where "alert fatigue" is first cited followed not more than 5 minutes later by "can't the system give us warning about that?" Really!?!

I can't in good conscience let the government regulations or insurance companies off the hook though either. As mentioned in the article briefly, regulations on how to submit data, what the data has to say, all the wierd hoops you have to jump through to get a claim processed and even more importantly what boxes to check so it doesn't get denied are ludicrous at this point. There is definitely pressure from these stringent and often not well planned out requrements which make EHR endeavors that much more complicated.Let's be really honest here, not all this software is that crummy. Many products are quite useful and can be tailored to meet the needs of providers of all types with proper engagement. An iterative, agile methodolgy needs to be used in order to get the best results.Finally, let's once again look at some of these complaints in a truer light. I have looked at medical records from my personal experience as well as my family member's experiences in both the paper and electronic world. The mistakes made in physician documentation are unchanged in this small sample between both environments--statements of complaint which were not discussed inserted, wrong medication names (and I'm talking on the lines of Zantac versus Pepcid here which could never be a system suggestion error) and the list goes on. Also, we have not noticed a difference in wait times at the clinic to see the doctor or actual amount of time spent with a physician between the paper world of yore and the electronic world of today. These differences from a patient's perspective are far more important than the number of clicks to complete a note!